New York Do Not Resuscitate Order (DNR) Form

The New York DNR (for Do-Not-Resuscitate) Form is a medical, legal document that a person needs to ban a medical procedure known as resuscitation. This ban will instruct paramedics (or other medical personnel) not to take action to bring a person to life. In particular, a DNR Form will restrict cardiopulmonary resuscitation (CPR).

CPR procedure includes the following measures:

  • Mouth-to-mouth breathing and indirect heart massage
  • Electric shock to restart the heartbeat
  • Breathing tubes to open the airway
  • Medication

With the signed DNR form, when a person is brought to a hospital, and their heart stops beating, or they stop breathing, paramedics will not perform CPR.

How to Get a DNR Form

It is best when you get the DNR form created before any emergency happens to you. This printable DNR form will let you decide whether or not you want to receive a CPR procedure. It is critical to remember that a DNR form only deals with cardiopulmonary resuscitation and does not consider other treatment procedures.

This means that if you would like to exclude other forms of treatment (certain medications, nutrition, other procedures like blood transfusion, etc.), you will need to consider signing additional medical forms.

A doctor writes the DNR form. Before you sign it, you will have to speak to your doctor. If you cannot do this for specific reasons, the form will be signed by your family or legal representative.

In Which Situations Do People Choose to Get a DNR Form?

Traditionally, patients choose to sign a DNR form when they are very old and feel that they have reached the end of their lives. In such cases, some people don’t want to undergo medical treatment when their heart stops beating. To make that possible, patients talk to their doctors to create a DNR order.

Such decisions are not easy to make because the patients’ families may have other opinions. However, a patient gets to decide what to do with their life. And that is why it is critical to determine whether or not you want to be CPRed.

To make the proper decision, your best choice is to talk to your doctor to assess your health condition and learn about prognoses. Also, a doctor will tell you about the pros and cons of CPR.

Finally, if you have a DNR form, you can change your mind at any time and request a CPR procedure.

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Download your fillable New York DNR form in PDF format.

Filling Out a New York DNR Form

The New York DNR form is a four-page document with several fields and boxes for a patient to insert their information. The New York ВТК form is created in strict accordance with the Senate Bill S7883. The mandatory signing requirements take two parties to create a document: a patient and a physician.

This is what you need to properly fill out the form.

1. Insert Your Personal Information

step 1 to filling out the new york dnr form - insert your personal information

This information will include:

  • your full name
  • full address
  • date of birth
  • gender
  • eMOLST number

2. Approve or Disapprove CPR

step 2 to filling out the new york dnr form - approve or disapprove cpr

In SECTION A of the document, you will need to check one of the two boxes:

  • the CPR Order box if you want to receive CPR
  • the DNR Order box if you don’t want to get CPRed when your heart stops beating.

3. Insert Instructions Regarding the CPR Consent

step 3 to filling out the new york dnr form - insert instructions regarding the cpr consent

In SECTION B of the document, name your decision-maker—a person who will consent to a CPR procedure if you cannot do so. Also, in this section, you will need to provide the names of the two witnesses.

4. Insert the Signatures of a Physician, a Nurse, a Practitioner, a Physician Assistant.

step 4 to filling out the new york dnr form - insert the signatures

5. Give Extra Directives

step 5 to filling out the new york dnr form - give extra directives

In SECTION D of the document, check the boxes related to several additional directives if you have any of them completed.

6. Specify the Orders Regarding Life-Sustaining Treatment

step 6 to filling out the new york dnr form - specify the orders regarding life-sustaining treatment

If you get hospitalized, your heart is beating, and you are still breathing, medical personnel will need to understand what type of life-sustaining treatment they can use.

This section (SECTION E) lists six orders related to life-sustaining procedures:

  • General treatment guidelines
  • Instructions for Intubation and Mechanical Ventilation
  • Future Hospitalization/Transfer
  • Artificially Administered Fluids and Nutrition
  • Antibiotics
  • Other instructions

step 6 to filling out the new york dnr form - section e

Below, you will need to put a signature, name your decision-maker, and two witnesses. Plus, you will need to check one of the boxes marking the person who made the decision.

7. Review and Renew The Form’s Terms

step 7 to filling out the new york dnr form - review and renew the form’s terms

SECTION F of the document is a chart listing the form’s review entries. This chart is for medical personnel only. Your physician, nurse, etc., must review the signed DNR from time to time and put down the results of reviews. This is especially critical if you move to a new place, have a major change in health status, or change your mind about your previous decisions documented in the form.

Published: Oct 18, 2021